✓ The authors report initial results and follow up using stent placement to treat atherosclerotic stenosis in vertebral arteries. Three patients with severe atherosclerotic vascular disease underwent vertebral artery stent placement using a balloon expandable stent. Medical therapy (aspirin and warfarin) and conventional percutaneous angioplasty failed to resolve the disease and the patients developed symptomatic restenosis within 3 months of angioplasty. Two patients had symptoms of anterior circulation ischemia with carotid artery occlusions and reduced supply to the anterior circulation from the stenosed vertebral arteries. One patient had recurrent posterior circulation symptoms. Stents were successfully placed in all three, resulting in immediate reversal of stenosis and resolution of symptoms. Clinical follow-up study (mean 9 months) has shown no recurrent symptoms in the patient with posterior circulation symptoms, but the two patients with anterior circulation ischemia did develop recurrent symptoms. Angiographic follow up in these two patients at 3 months and 1 year, however, demonstrated continued patency of vertebral artery lumina. They underwent extracranial—intracranial bypass surgery to relieve their symptoms. This experience suggests stents can be placed without complication in the proximal vertebral arteries and may have an adjunctive role in the treatment of atherosclerotic cerebrovascular disease following unsuccessful angioplasty.
Gayle S. Storey, Michael P. Marks, Michael Dake, Alexander M. Norbash and Gary K. Steinberg
Richard J. Bellon, Amon Y. Liu, John R. Adler Jr. and Alexander M. Norbash
✓ The authors present the case of a 61-year-old man with an indirect carotid—cavernous fistula (CCF). Many now advocate a primary transvenous approach to deal with such lesions, with packing and thrombosis of the cavernous sinus leading to fistula obliteration. Transvenous access to the cavernous sinus via the inferior petrosal sinus is the usual route of access; both surgical and transfemoral superior ophthalmic vein approaches are also well described. In the case presented, the anatomy of the CCF was unfavorable for these approaches and its dominant venous egress was via a single enlarged arterialized cortical vein. The cavernous sinus was accessed with a transfemoral retrograde approach to the cortical draining vein. Successful CCF embolization was documented radiographically and clinically. To the authors' knowledge, this procedure has not been previously described in the English literature.
Ioannis Karakis, Thanh N. Nguyen, Viken L. Babikian and Alexander M. Norbash
Intracranial atherosclerotic disease accounts for 5–10% of ischemic strokes in the US. Lesions located in the anterior cerebral artery territory are infrequently reported. Patients in whom medical therapy fails are at a high risk for recurrent ischemic events, in which case intracranial angioplasty or stenting may be a reasonable therapy. There is a paucity of literature describing angioplasty of fixed atherosclerotic lesions affecting the anterior cerebral artery territory, and especially the A2 segment. This case illustrates that this vessel segment may be treated with balloon angioplasty.